Providing safer opioids to people who use drugs is the opposite of “giving up” on them

As unprecedented numbers of Canadians are dying from the greatest drug toxicity crisis in our history, British Columbia is expanding harm reduction services for people who use opioids. This will include, in coming months, a pilot program that uses dispensing machines to distribute safer pharmaceutical-grade opioids to drug users. Some in the medical community have criticized B.C.’s plan, arguing that public health leaders are “giving up on addicts” and opting to “just keep them on drugs.” Canadians must understand that both science and epidemiology rebut these views. In responding to the opioid crisis, B.C. hasn’t given up on anyone.

Rising mortality in B.C. is not associated with rising drug use, per se, but with the prevalence of toxic and cheap synthetic opioids like fentanyl and its analogs. From 2012 to 2017, the number of unintentional illicit drug overdose deaths in B.C. surged from 202 to 1,422 annually, while during this same period the number of these deaths involving fentanyl increased from 12 to 1,156 per year—a staggering jump from four percent to 81 percent of cases. By providing a safer supply of drugs, B.C. is preventing more of these tragic overdose deaths from happening.

Offering safer opioids by no means takes away from addiction treatment or prevention. In other words, public health authorities do not need to choose between prevention of substance use and prevention of harms from substance use. A key tenet of harm reduction is to provide people who engage in risky behaviours access to additional recovery services by meeting them where they are first and then determining their needs. As Dr. Mark Tyndall, executive director of the B.C. Centre for Disease Control, puts it, “You cannot get someone into rehabilitation when they’re dead.” As a non-judgmental intervention, harm reduction connects marginalized individuals with broader health care, thereby enabling health and social systems to begin addressing risk factors for substance use and poor health such as homelessness, mental illness and trauma. Even with an inclusive ethos, though, rehabilitation and prevention measures take months or even years to realize an effect.

In any chronic health condition—whether diabetes, arthritis or opioid addiction—multiple treatment options should be available. Thankfully, we have strong evidence demonstrating cost-effective benefits from “conventional” treatments for addiction, like methadone and buprenorphine/naloxone (Suboxone) maintenance therapy, as well as from structured slow-release morphine maintenance, supervised injectable diacetylmorphine (pharmaceutical heroin) and hydromorphone therapies. If these services cannot reach everyone who may benefit, B.C’s idea of lower-threshold access to pharmaceutical opioids follows the proven logic of harm reduction.

Tyndall concedes that distributing safer opioids may leave one feeling uneasy, particularly given the dominant narrative that the crisis is rooted in the way physicians have prescribed opioids in recent decades. B.C. plans to mitigate public health risk by distributing hydromorphone pills through the dispensing machines, which will use biometric data to identify patients, ensuring that medications are securely dispensed to authorized users. Individuals would be assessed, registered and issued a card to access two or three pills up to three times per day, thereby reducing the risk of theft for purposes of diversion. All things considered, these dispensers are less traditional vending machines, as characterized in the media, and more high security ATM-like machines. If successful, this program could offer a way forward not just for those struggling in Vancouver’s Downtown Eastside—which, in truth, is likely Canada’s safest place to overdose—but also in under-resourced communities increasingly affected by the crisis.

In public health emergencies involving novel hazards, authorities necessarily find themselves having to mobilize quickly to develop pragmatic interventions with the best possible, and often less than perfect, evidence. This crisis is no different. Providing safer opioids to those at highest risk of deadly overdoses has the potential to connect patients to life-saving services, decrease the spread of more toxic opioids, curtail social dysfunction and reduce the transmission of infectious diseases. If it takes an innovation like a hydromorphone-dispensing machine to make even a small difference, then so be it. Importantly, these interventions also send a message to those struggling with substance use: We haven’t given up on you.

Max Deschner is a medical student at the University of Ottawa. Jonathan Gravel is an epidemiologist and a family medicine resident physician at the University of Toronto. The authors thank Dr. Mark Tyndall and Dr. Hakique Virani for their insights.

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6 comments

anonMarch 22nd, 2018 at 1:32 am

A question: Are there more problems from people directly using synthetic opioids that cause overdoses, or using other drugs that are (unknown to them) laced with synthetic opioids? I have seen data that the majority of heroin is now being found to be laced with fentanyl, and even marijuana can have fentanyl and cause overdose. Am wondering how much of the overdose crisis/epidemic this new dispensing system will address. And how to address the lacing of other drugs with these deadly synthetics?

The problem that I see myself is that when people are unable to know how strong a drug is, the situation only ends badly. That is why people should have a government make sure they are getting the proper dosage. However some pain medication such as hydrocodone have a very short active half life usually about 2 to 3 hours. They are prescribed this and only prescribed one pill every 8 hours leaving them in severe pain most of the time. This problem is easy to solve but too many that are in control of the system refuse to even realize the problem of constant severe pain with short times of relief is the problem. If people in chronic pain are on a constant dose that allows them enough relief that they are not constantly suffering the problems would not exist and deaths would not be happening in the large numbers we have now.

Most definatley the highest risk is people buying adulterated Street opiates such as heroin which now always have fentynal in them or sometimes have no heroin in them. A person utilizing a regulated, unadulterated opiod like Dillaudid is much safer because they know exactly what the dose is and what the drug is. The thing with fentynal is that people can end up with hot spots, which spots in the mix where the fentynal didn’t mix evenly and ends up stronger in one part of the batch then the other.

That is a good idea, as many including myself do have a very difficult time getting medications for severe pain. I have medically verified problems that cause my pain. Without such medications I would not be able to function even at a minimal level. Problem is that in our society we have far too many doctors and other medical professionals that give up too soon when people have medical problems that are painfull and life threatening. This forces many to either choose to die or find medications themselves for their problems. I have also an immulgloblin g diffency that causes me to never get over infections in my sinuses and chest. Then I have to either take care of it myself or go to a doctor each week. The pain medication problem is that quite often doctors do not believe people are in as much pain as they are and are only seeking drugs. When the pain is so much that death looks better than life with what is available we have the situation that we have now with all the deaths as a result. To many doctors and those in government that are never second guessed about how they are actually feeling they think that just because people get medications elsewhere they are only abusing them. This is giving up on people at its worst. This is how the usa is where it is cheaper to get help from drug dealers for many than to get help from medical professionals. That is because such people are not able to afford the tests or have the time available with dealing with life in so many other ways that they are unable to get help with medical providers. I am finding more and more that the people in the world enjoy causing the suffering of others and make up excuses all the time and more laws to only make the problem worse. Doctors and others cant feel the pain so they have no real idea of what most people are going through. I decided that I do not want a child of mine to suffer as I do, so I have no children my parents would have liked to have grand children but it is just not going to happen.

I will say if there were not a few that depend on me and that includes my pets friends and family. Along with so far only one doctor that got me onto a long acting pain medication. Chances are I would have died a few years ago, as there is more concern about what people are taking. Instead of their health and why they are taking it. The solution is working with people to solve the problem, as people that are in a workable and effective program usually do not take things they are not prescribed or end their life to end the suffering.

I have in the past been a functional addict. Opiates was my drug of choice. I had a very successful screen printing and embroidery business with 25 employees and customers, through Reebok and Adidas, as in NHL, NBA, and NFL. Unfortunately the wreckage of the past caught me on the fly. A carrier of Hep C matured into an Interferon 8 month stint in bed. I have dealt with pain since in my early 30’s. It is very difficult for a Doctor in the U.S. to prescribe me an opioid. I would be very functional and have a higher quality of life with this rather than the non effective and high risk of side effects caused by meds such as Gabapentin. Now in the early stages of Alzheimer’s at age 71 I am soon to be sentenced to a life of diapers and a wheel chair while being decimated from Alzheimer’s. I am tired of going to a Doctor and being treated as an addict before treatment as a patient. If I wanted to get high there are enough street drugs to have at it. I have a sobriety date of December 20, 1988. Would it be feasible for me to move to Canada where there may be a higher quality and standard between a Doctor/Patient relationship. I have Scoliosis, serious cartilage loss in all my bone joints. Lower lumbar discs are a mess. I guess what I’m doing is begging for answers that will at least allow me some living rewards.

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